Advances in Plastic & Reconstructive Surgery © All rights are reserved by Richard Moufarrège, et al.

Review Article ISSN: 2572-6684 The Total Submuscular Augmentation

Richard Moufarrège1, George Dimitropoulos1, Hussein Assi2 1University of Montreal Hospital Centre (CHUM). 2Department of Medicine, University of Montreal.

Abstract Most called retromuscular or retropectoral breast augmentations consist in inserting the behind only one muscle on the anterior aspect of the thorax, that is to say behind the pectoralis major muscle. This will mean that one third or one quarter of the prosthesis will not have a muscular cover and will be in direct contact with the breast tissue. The lack of muscle protection on a part of the prosthesis surface will lead to a possible wrinkling show on the inferior lateral aspect of the breast and a possible “double-bubble” phenomenon. These two disadvantages could be circumstantial but there is one other inconvenience, much more frequent, which is the loss of the erogenous sensation of the nipple. That problem is a consequence of the prosthesis insertion behind the only pectoralis major muscle, interrupting often the continuity of three intercostal nerves (4th, 5th and 6th), responsible of erogenous sensation of the nipple. Our approach promotes the insertion of the prosthesis behind the four muscles of the anterior thorax through a low incision in the anterior oblique and the serratus anterior, and an undermining superiorly, medially and laterally to create a pocket behind the four muscles: the anterior oblique, the serratus anterior, the pectoralis minor and the pectoralis major. This surgery will preserve the functions of the three intercostals nerves, thus the erogenous sensation and contraction of the nipple and nipple areola complex. Keywords: ; Retropectoral Augmentation; Total Submuscular Augmentation; Erogenous Sensation of the Nipple; Double-Bubble Avoidance.

Introduction upper two-thirds or three-quarters. That means that one-quarter or one-third of the breast does not cover the pectoralis major muscle but The simple subpectoral breast augmentation is known since only a small part of the pectoralis minor, the serratus anterior and the several decades. This technique has gained popularity for many external oblique muscle. reasons, such as the support of the implant by a muscular hammock reducing the pressure on the skin envelope, which otherwise would Classically, the majority of surgeons who perform the subpe- have to support exclusively the implant. The second advantage of this ctoral approach in breast augmentation, whether for aesthetic or technique was the presence of a thick muscular layer between the reconstruction augmentation, make their incision in the inframa- implant and the skin, especially in case of a small-sized or an mmary fold [Figure 1], dissect from caudal to cranial from the involuted breast. The most important factor which popularized the incision level in a retroglandular plan until the inferior lateral border submuscular technique was the tremendous increase of the use of of the pectoralis major. At this level, they elevate the pectoralis major saline implants during and after the “silicone crisis” in the 1990s. The and thus create the pocket meant to receive the implant. However, saline implants presented the drawback of implant rippling when they the implant, which is destined to increase the volume of the breast or, were placed in the subglandular space because the breast tissue did in case of a , to replace the missing breast, has to respect a not offer enough thickness to cover the rippling. The adoption of the precise position and cannot lie into a hazardous position. Inversely, subpectoral approach gave a supplementary layer of tissue in front of the implant cannot be hidden completely under the pectoralis major the implant and so the rippling was efficiently covered. muscle because otherwise it will become deformed [Figure 2a & 2b]. The standard approach in subpectoral breast augmentation This leads to an unavoidable result: with the simple subpectoral breast augmentation, the pectoralis major can cover the two-thirds or This technique, as its name mentions, consists of inserting the at best three-quarters of the implant. One-third or one-quarter of the implant under the pectoralis major muscle. implant is only covered by the breast on its inferior lateral aspect According to the anatomical studies of the thoracic wall, the fan- [Figure 2a & 2b]. shaped pectoralis major muscle, which extends from the axilla to the While the central part of the implant is covered by the pectoralis sternum, is in close relation with the posterior face of the breast on its major muscle and the existing breast, the lateral part of the implant is sometimes only covered by the skin in the cases of small or involuted *Address for Correspondence: Dr. Richard Moufarrège, MD, FRCS (C), . The consequence is having the effect of “fleur de peau” (in Professor of at University of Montreal, 1111 St-Urbain, Suite case of thin-skinned patients) and the presence of rippling at the 106, Montreal, Qc, H2Z 1Y6, Canada, Tel: (514) 944-6688; E-Mail: lateral aspect of the breast. The rippling is present even in the case of [email protected] silicone cohesive implants, in various degrees ranging from the Received: October 08, 2018; Date Accepted: December 27, 2018; Date perception of these folds only by touch to visible rippling in most Published: December 28, 2018. serious cases.

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useful characterization of serotonin receptor subtypes in the treatment of Richard M, George D, Hussein A. The Total Submuscular Breast Augmentation. Adv Plast Reconstr Surg, 2018; 2(4): 237-242.

Literature review According to the literature, the majority of surgeons use the simple subpectoral approach in their submuscular breast augme- ntation procedures. Maher et al.1, Matarasso2, Tebbetts3,4, Davidson5, Strasser 6, De Haan et al.7, Lesavoy et al.8, Zeitouné et al.9, Hage et al.10, Shi et al.11 and Vidya et al.12 perform breast augmentation behind the pectoralis major which implies that one third of the prosthesis is not covered by the muscle in its inferior lateral aspect. Graf et al. [13] and Tebbetts [14] proceed behind the pectoralis major fascia using a submammary approach. Skin incision Pelle-Ceravolo et al. [15] creates his implant pocket behind the pectoralis major using a vertical incision behind the lateral free edge of the muscle. Barnett [16] prepares his implant pocket using a retrofascial approach of the pectoralis major trough an axillary passage.

Figure 1: Breast total submuscular augmentation: skin incision in the subma- Price [17] advocates the subpectoral addition using the axillary mmary fold. approach. 1. Sternum Pound [18] and Rinker [19] use a retropectoral approach starting 2. Pectoralis major from the . 3. Prosthesis contour limit 4. Pectoralis minor All the authors mentioned above therefore use an approach 5. Pectoralis major 1 6. Prosthesis behind the pectoralis major muscle whether submuscular or subfa- 7. Skin incision (level) 2 scial to perform breast augmentation. Consequently, one third of the 8. Serratus anterior muscle prothesis does not get its surface covered by any muscle. 4 3 9. External oblique muscle 10. Rectus abdominis 5 Hendricks [20] appears to be the only author presenting breast augmentation behind the four muscles using, however, a periareolar approach. This allows him to penetrate the submuscular space 6 centrally and dissect centrifugally an implant pocket behind the four muscles of the anterior hemithorax. This approach, however, puts in 7 danger the continuity of the intercostal nerves even though, in some 8 cases, we can hope for nerve sparing. 10 Finally, our literature review reveals that only Hendricks places the prosthesis behind the four muscles of the anterior hemithorax. However, his approach differs from ours in that he creates a submuscular implant pocket trough a breach in the pectoralis major muscle and a centrifugal dissection. This approach cannot ensure the Figure 2a: Traditional retropectoral augmentation : Insertion of the prosthesis integrity of the intercostal nerves. under the pectoralis major Our approach, which consists in undermining the four muscles starting from a horizontal incision in the external oblique and the 1 serratus anterior muscles is the only way to preserve nerve integrity 2 and thus the erogenous sensation of the nipple. 3 4 Breast reconstruction by subpectoral implant 5 In case of retropectoral breast reconstruction, the mastectomy 6 that precedes leaves the implant without any breast coverage in the 7 1. Intercostal nerve (5th or 6th extremity) inferior lateral third of the breast surface and therefore the prosthesis 8 2. Breast gland tissue 9 3. Pectoralis major muscle will sit in the subcutaneous layer on its lateral anterior aspect. That’s 4. Prosthesis 10 why surgeons are obliged to use dermal matrices in order to restore 5. Interrupted intercostal nerve the lack of muscular support of the implant. We all know the inherent 6. External oblique muscle 7. Interrupted intercostal nerve risk of these matrices in terms of seroma (risk multiplied by four) and 8. Pectoralis minor infection (risk multiplied by five and a half) [21-26]. 9. Serratus anterior muscle 10. Serratus anterior muscle Breast augmentation by axillary approach 11. Rib 12. Intercostal nerve (5th or 6th) The breast augmentation by axillary approach is attractive by the fact that it gives the impression of protecting the implant by the absence Figure 2b: Traditional retropectoral augmentation: Transverse section of the of incision in the inframammary fold. In fact, once the implant has breast following insertion of the prosthesis.

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passed under the humeral portion of the pectoralis major, it is inserted into the pocket covered by the pectoralis major at its upper medial two-thirds or three-quarters. If the implant is well placed, it is situated under the skin and the breast and in front of the musculature (pectoralis minor, serratus anterior and external oblique muscles) 1 especially in the inferior lateral area of the breast [Figure 2a & 2b]. 2 1. Sternum 2. Pectoralis major The erogenous sensation of the nipple 3. 4th intercostal nerve 3 4. Pectoralis minor We know that the erogenous sensation of the nipple originates 5. 5th intercostal nerve from the superficial branch of the fourth, fifth and sixth intercostal 4 6. Serratus anterior muscle 5 7. 6th intercostal nerve nerves. 6 8. Serratus anterior muscle 7 9. External oblique muscle These nerves become subcutaneous approximatively at the level 8 10. Muscle incision of the posterior axillary line and they lie into the areolar tissue on the 11. Rectus abdominis 9 surface of the serratus anterior, the pectoralis minor and the 10 11 pectoralis major muscles. When the fourth, fifth and sixth intercostal nerves arrive at the free border of the pectoralis major, they continue their course along its anterior aspect until the vertical axis of the breast, where they arise anteriorly into the breast and innervate the nipple-areolar complex and the surrounding areas. This portion of these three nerves at the level of the free border of the pectoralis major muscle is the most vulnerable during the dissection of the subpectoral Figure: 3a Breast total submuscular augmentation: pre-operative anatomy. space. Sometimes the nerves are not divided but rather compressed or stretched by the finger during the dissection. Generally speaking however, the risk of cutting these nerves is high. In this context, the fifth and sixth intercostal nerves are almost always traumatized during 1 2 the submuscular breast augmentation while the fourth nerve is hurt to 3 a lesser extent. 4 5 6 The total submuscular breast augmentation 7 I practice this technique of breast augmentation since more than 25 years, being obliged to use saline implants during the so called “silicone crisis”. 1. 5th intercostal nerve 2. Breast tissue The incision is performed at the inframammary fold [Figure. 1]. 3. External oblique muscle 4. Pectoralis major As I still prefer saline implants, the incision is not bigger than 3 cm. 5. Pectoralis minor After penetrating the underlying subcutaneous tissue, the muscular 6. Serratus anterior plane is incised horizontally using scissors [Figure 3a] [10]. The muscle 7. Rib muscular incision is extended medially and laterally; at this level (seventh and eighth rib), it implicates, as well, the serratus anterior and external oblique muscles [Figure. 3a #10]. From this moment on, Figure 3b: Transverse section of the left breast before augmentation. the dissection is done close to the ribs under the serratus anterior, external oblique, pectoralis minor and finally, pectoralis major muscles [Figure. 5]. The implant pocket stays submuscular even in the lateral aspect where the pectoralis major is absent. The implant is placed into this space [Figure 4a, 6, 7]. The muscular plane is closed with 1 or 2 sutures. As I put saline implants, I take away the small 1 2 1. Sternum tube of the valve filling after the implant is filled, and then I put again 2. Pectoralis major this small tube into the pocket just before the muscle closure. Once 3 3. Prosthesis upper contour the skin is sutured, this tube serves to inject into the submuscular 4. Pectoralis minor pocket a Marcaine solution (5 cc Marcaine 0.5% with 25 cc saline 5. Serratus anterior muscle 4 6. Prosthesis inferior contour 0.9%) after what the tube is removed. This infiltration provides an 7. Muscle incision 8. External oblique muscle analgesic effect on the detached muscles which can last up to 5 12 hours. 9. Rectus abdominis 6 The advantages of the total submuscular breast 7 augmentation compared to the standard simple subpectoral 8 breast augmentation 9

1. Better muscular hammock The total submuscular breast augmentation should provide a better muscular hammock for the support of the implant’s weight. The Figure 4a: Total retromuscular augmentation : muscle contour after prosthesis insertion.

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1 2 3 4 1 1. Sternum 5 2. Pectoralis major 6 2 3. Upper limit of pocket 7 dissection 3 4. Pectoralis minor 8 5. Retractor 4 6. External oblique muscle 1. Intercostal nerve (5th or 6th extremity) (elevated fibers) 9 2. Breast gland tissue 7. Muscular incision 5 10 3. Pectoralis major muscle 8. Cohesive prosthesis 4. Pectoralis minor 6 9. Rectus abdominis 5. External oblique muscle 7 6. Serratus anterior muscle 8 7. Prosthesis 9 8. Rib 9. Serratus anterior muscle 10. Intercostal nerve (5th or 6th extremity) Figure 4b: The total retromuscular augmentation as advocated by Moufarrege Transverse section of the breast following insertion of the prosthesis.

Figure 7: T7otal retromuscular augmentation: inserting silicone cohesive pro- sthesis. implant which is supported solely by the pectoralis major muscle puts on the skin a weight leading to a skin stretching and consequently, it 1 1. Sternum leads to a breast ptosis in a short, middle or long term depending on 2. Pectoralis major 2 3. Upper limit of the implant size. submuscular dissection 3 4. Pectoralis minor In the contrary, putting the implant completely under the four 5. Retractor muscles, as described before, should offer to the implant a support by 6. Elevated external 4 a more complete hammock and delays the breast ptosis in compari- oblique fibers son to the standard partial retropectoral breast augmentation. This 7. Muscle incision 5 8. External oblique way of using the four muscle protection should avoid the famous muscle “double-bubble” deformity described in the simple retro-pectoral 6 9. Rectus abdominis augmentation. 7 8 2. Better coverage of the implant 9 The total submuscular breast augmentation provides a better coverage of the implant by the four muscles of the thoracic wall on every side of the implant especially on its lateral and inferior aspect. In fact, the standard subpectoral breast augmentation leaves the implant uncovered by muscle and covered only by skin on its lower Figure 5: Total retromuscular augmentation: preparing total submuscular pocket. lateral third of its surface. Putting the implant into the total submuscular space as we described previously will allow the implant to be covered by muscles on its whole surface and consequently will allows to avoid the rippling which could otherwise show on the lateral aspect of the breast. 1 3. Sparing of the erogenous sensation of the nipple 2 1. Sternum 2. Pectoralis major The introduction of the implant in the standard subpectoral 3 3. Upper limit of submuscular dissection technique is often accompanied by a lesion of the fourth, fifth and 4. Pectoralis minor sixth intercostal nerves which leads to the loss of the erogenous 4 5. Retractor sensation of the nipple [Figure 2b]. 6. Elevated external 5 oblique fibers The total submuscular breast augmentation as proposed by us 7. Muscle incision should not have any negative effect on these nerves so the erogenous 6 8. External oblique 7 muscle sensation of the nipple is preserved [Figure 4b]. 9. Rectus abdominis 8 4. Crucial role of the total submuscular position in breast reco- 9 nstruction The breast reconstruction technique with a total submuscular implant provides an efficient coverage and avoids the use of supplementary material by placing the implant under the four muscles of the thoracic wall by an incision in the serratus anterior Figure 6: Total retromuscular augmentation: preparing total submuscular pocket. and the external oblique.

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The breast reconstruction with the implant placed only under References the pectoralis major [Figure. 3a & 3b] leaves a big portion of the 1. Mahler D, Ben-Yakar J, Hauben DJ. The retropectoral route for breast augmentation. implant under the skin without muscle coverage. The use of dermal Aesthetic Plast Surg. 1982; 6: 237-242. [Crossref] matrices has been adopted by plastic surgeons as a solution for 2. Matarasso A and OHZ Hutchinson. Augmentation mammaplasty: Subpectoral augmentation using the periareolar or inframammary approach. Operat Techniq providing support and protection to the implant. The use of these Plastic Reconstr Surg. 2000; 7: 93-99. [Crossref] matrices has two Significant drawbacks: 3. Tebbetts JB. Dual Plane Breast Augmentation: Optimizing Implant-Soft-Tissue a. Relationships in a Wide Range of Breast Types. Plast Reconstr Surg. 2006; 118: 81S- The first problem is related to the high complication rate with 98S. [Crossref] the use of these matrices. 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Using an Alternative Surgical Technique. Aesthetic Plast Surg. 2007; 31: 147-153. Although our practice has regularly shown all benefits described [Crossref] in this article including avoidance of “double-bubble” deformity, 21. Qureshi AA, Broderick KP, Belz J, Funk S, Reaven N, Brandt KE, et al. Uneventful lower rates of ptosis and most importantly – preservation of the versus Successful Reconstruction and Outcome Pathways in Implant-Based Breast erogenous sensation of the nipple, a retrospective study will be Reconstruction with Acellular Dermal Matrices. Plast Reconstr Surg. 2016; 138: conducted in the near future comparing our series with the 173e-183e. [Crossref] 22. Israeli R. Complications of acellular dermal matrices in breast surgery. Plast Reconstr traditional dual plane technique retrieved from the literature. Surg. 2012; 130(5 Suppl 2): 159s-172s. [Crossref] 23. Ranganathan K, Santosa KB, Lyons DA, Mand S, Xin M, Kidwell K, et al. Use of Acknowledgements Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal? Plast Reconstr Surg. 2016; 138: 148e- Not applicable 149e. [Crossref] 24. Lopez J, Prifogle E, Nyame TT, Milton J, May JW Jr. The Impact of Conflicts of Funding Interest in Plastic Surgery: An Analysis of Acellular Dermal Matrix, Implant-Based The authors did not receive any funding from any institution or Breast Reconstruction. Plast Reconstr Surg. 2014; 133: 1328-1334. [Crossref] company. 25. Wagner DS. Discussion: Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction Are All Acellular Dermal Matrices Created Equal? Plast Reconstr Surg. 2015; 136: 654-656. [Crossref] 26. Chun YS, Verma K, Rosen H, Lipsitz S, Morris D, Kenney P, Eriksson E. Implant- based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg. 2010; 125: 429-436. [Crossref]

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